Sch 5APPLICATION FOR REGISTRATION OF A LODGING HOUSE

SCHEDULE 5—APPLICATION FOR REGISTRATION OF A LODGING HOUSE [Clause 8.3] I/We ................................................................................................................................................................. of ...................................................................................................................................................................... apply for the registration of premises situated (or to be situated) at ......................................................... .......................................................................................................................................................................... as a lodging house to be classified as— (Tick which is to apply) and for my name to be entered in the Register as the keeper of the lodging house. DESCRIPTION OF LODGING HOUSE— Number of storeys: ............................................. Number Area Laundries/toilets/bathrooms ............................ ............................ Bedrooms ............................ ............................ Dining Rooms ............................ ............................ Kitchens ............................ ............................ Sitting Rooms ............................ ............................ Other (Specify)— ................................................................................... ............................ ............................ Rooms for lodgers Number Area Bedrooms ............................ ............................ Dining Rooms ............................ ............................ Kitchens ............................ ............................ Sitting Rooms ............................ ............................ Other (Specify)— ................................................................................... ............................ ............................ Sanitary conveniences for male lodgers Number Toilets ............................ Urinals ............................ Baths ............................ Showers ............................ Hand wash basins ............................

4 January 2017 GOVERNMENT GAZETTE, WA 45 Sanitary conveniences for female lodgers Number Toilets ............................ Baths ............................ Showers ............................ Hand wash basins ............................ Laundry facilities Number Wash-troughs ............................ Washing machines ............................ Drying cabinets or clothes lines ............................ Additional Details— (a) Lodgers’ meals will/will not be provided by the manager/keeper/lodgers. (b) The keeper will/will not reside continuously on the premises. (c) Name and occupation of proposed manager if keeper resides elsewhere— ........................................................................................................................................................... (d) There will be ................. family members residing on the premises with the keeper/manager. ————